Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.33(b)(1) | The assessments for Individual #2 dated 10/31/13 and 10/29/14 were written by direct support staff and only reviewed by the program specialist. The direct support staff's handwriting was the only writing in the assessment. | The program specialist shall be responsible for the following: Coordinating and completing assessments. | 2380.33(b)(1) The regulation was reviewed with the Program Supervisor by the Assistant Director on 11/16/2015 (Attachment #37). An electronic version of the annual assessment is now being used in all day programs. A recently completed annual assessment for individual #2 is included for review (Attachment #38). |
| Implemented |
2380.33(b)(18) | Individual #1 had a seizure disorder. His Individual Support Plan (ISP) stated that his seizures could last 3-4 mins. He did not have a seizure protocol for staff to follow if he had a seizure at the day program. There was no documentation that any staff working at the facility had training on seizures/protocols/types of seizures/how to recognize seizures/etc. Individual #1's ISP did list some symptoms that he exhibits during a seizure (clicking noise, eyes fluttering, etc). However, his start date at the day program was 1/5/15 and only Staff #1 and #2 were trained on his ISP after his start date. Individual #1 was also a choking risk and there wasn't a choking prevention plan. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | 2380.33(b)(18) The regulation was reviewed with the Program Supervisor by the Assistant Director on 11/16/2015 (Attachment #39). The Program Supervisor received a seizure protocol written by a CSG Program Director (Attachment #40. The protocol is appropriate for day program use and was reviewed by all day program staff (Attachment #41). |
| Implemented |
2380.34 | Staff #3 was trained in "Job Description and Responsibilities" on 6/26/14, "Van Training and Driving Safety" on 6/21/14, "Van Training Checklist" on 6/24/14, "Alternatives Staff Manual" on 6/26/14, and "Van Training Checklist" again from 6/23/14 to 6/24/14. The Van Training Checklist included training on the accident forms to fill out in the event of a vehicle accident whether it be in staff's personal vehicles or company vans. Staff #3 recorded an incident on the Incident Log in Individual #1's program book. She recorded that on 12:05pm on 10/9/15, she was taking Individual #1 to the Grantville market and they were hit by a car at a red light. She recorded that there were no injuries and no action was taken. Under her statements, Staff #2 recorded that he notified Staff #4, the UCP Assistant Director. There wasn't a time or date listed for when Staff #4 was notified of the incident. Staff #2 also recorded on the incident log that he "spoke with Raquelle Coleman (Assistant Program Director) who said that she didn't feel we need to seek medical attention for Individual #1". Again, the log did not note when Raquelle was notified, who she was, and why she determined that medical attention did not need to be sought. After speaking with Staff #2 during the annual inspection, he clarified that Staff #1 and #3 were in the vehicle along with Individuals #1 and #3. There wasn't an incident log for Individual #3 in his program book. Medical attention was not sought for either of the Individuals. Staff #2 also stated that Staff #3 was driving her own personal vehicle when they were struck by another car. Staff #3 did not fill out any of the accident forms, did not call 911 at the scene of the accident, but instead drove her vehicle back to the program to report there was an accident. Staff #3 did not follow the Driving Policy or the Transport of Consumers in Employee Vehicles Policy. | A direct service worker shall be responsible for the daily care, training and supervision of individuals. | 2380.34 The regulation was reviewed with the Program Supervisor and his staff by the Assistant Director on 12/9/2015 (Attachments #35 & #36). In addition to the regulation, was a review of the agency driving policy, Transport of consumers in employee vehicles and accident reporting procedures. |
| Implemented |
2380.111(c)(4) | The physical exam for Individual #1 did not include a hearing exam. Everything was left blank in spots where a hearing evaluation was to be completed. There wasn't documentation of follow up by the provider to get clarification on his last examination. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | 2380.111(c)(4) The regulation was reviewed with the Program Supervisor by the Assistant Director on 11/30/2015 (Attachment #33). Individual #1 is due for his annual physical exam by 01/19/16. The Program Supervisor will ensure that all sections of the physical exam form are complete and this information will be forwarded no later than 1/31/16. |
| Implemented |
2380.111(c)(10) | The physical examination form for Individual #1 did not have a spot for emergency information. Dominic had a seizure disorder and was a choking risk. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | 2380.111(c)(10) The regulation was reviewed with the Program Supervisor by the Assistant Director on 11/30/2015 (Attachment #34). Individual #1 is due for his annual physical exam by 01/19/2016. The Program Supervisor will ensure that all sections of the physical exam form are complete and this information will be forwarded no later than 1/31/2016. |
| Implemented |
2380.124(a) | Individual #1's medication logs for the past year, from October 2014 until October 2015, did not have a time listed for when their calcium antacid tablet was administered. The medication logs for July and August 2015 for Individual #1 didn¿t list a time when Lorazepam was administered. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | 2380.124(a) The regulation was reviewed with the Program Supervisor by the Assistant Director on 12/09/2015 (Attachment #31). The Program Supervisor and the two medication administration trained staff had a review of module 8 of the Medication Administration trainer¿s manual and how to accurately document a MAR (Attachment #32). The Assistant Director will do monthly MAR checks until assured MAR¿s are being documented correctly. |
| Implemented |
2380.173(1)(i) | Individual #1's date of entry to the program was not in the record. The date of entry was not recorded anywhere on paper or electronically. | Each individual's record must include the following information: Personal information including: The name, sex, admission date, birthdate and social security number. | 2380.73(1)(i) The regulation was reviewed with the Program Supervisor by the Assistant Director on 12/09/2015 (Attachment #25). The personal information form for individual #1 was updated at the time of the licensing inspection. His admission date was added as determined by attendance logs (Attachment #26). |
| Implemented |
2380.173(1)(iii) | The language understood by Individual #1 was missing from their record. | Each individual¿s record must include the following information: Personal information including: The language or means of communication spoken or understood by the individual and the primary language used in the individual¿s natural home, if other than English. | 2380.173(1)(iii) The regulation was reviewed with the Program Supervisor by the Assistant Director on 12/09/2015 (Attachment #27) The personal information form for individual #1 was updated at the time of the licensing inspection (Attachment #28). The language or means of communication spoken or understood by the individual was added at that time. All of the consumers records are update. |
| Implemented |
2380.173(9) | The physical exam form for Individual #1 that was completed on 1/20/15, stated that he had no known drug allergies. On another spot on the same physical exam form, it stated Individual #1 was allergic to Divalproex Sodium and had seasonal allergies. The Individual Support Plan (ISP) for Individual #1 stated he was allergic to Depakote and had seasonal allergies. The same physical exam form stated his food was to be cut into 1 inch pieces. Individual #1's assessment only stated that he was to eat his food slowly. Individual #1's ISP stated he had a behavior support plan but that it wasn¿t restrictive and it is. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | 2380.173(9) The regulation was reviewed with the Program Supervisor by the Assistant Director on 12/09/2015 (Attachment #29). A team meeting was held for individual #1 on 10/26/2015 and the Program Supervisor requested information to update our records. The Program Supervisor then sent an email to the team on 12/11/2015, again requesting the information that is needed for our records as well as needed to update the ISP (Attachment #30). |
| Implemented |
2380.181(e)(6) | The assessment for Individual #2 did not include their ability to safely use or avoid poisonous materials. | The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | 2380.181(e)(6) The regulation was reviewed with the Program Supervisor by the Assistant Director on 11/30/2015 (Attachment #17). The annual assessment for individual #2 was completed on 10/28/2015, including her ability to safely use or avoid poisonous materials (Attachment #18). |
| Implemented |
2380.181(e)(13)(ii) | The assessment for Individual #2 did not include their progress over the last 365 calendar days and their current level in motor and communication skills. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | 2380.181(e)(13)(ii) The regulation was reviewed with the Program Supervisor by the Assistant Director on 11/30/2015 (Attachment #19). The annual assessment for individual #2 was updated on 10/28/2015 including progress and growth in motor and communication (Attachment #20). |
| Implemented |
2380.181(e)(14) | The assessment for Individuals #1 and #2 did not contain their knowledge of water safety and their ability to swim. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. | 2380.181(e)(14) The regulation was reviewed with the Program Supervisor by the Assistant Director on 11/30/2015 (Attachment #21). The assessments for individuals #1 and #2 were updated to include their knowledge of water safety and their ability to swim (Attachments #22 and #22a). The electronic version of the assessment is being utilized and the section on water safety changed to read logically (Attachment #22). |
| Implemented |
2380.181(f) | The assessment for Individual #1 was not sent to his behavior support person or his mother who were team members at the time of the assessment dated 2/18/15. | The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). | 2380.181(f) The regulation was reviewed with the Program Supervisor by the Assistant Director on 11/30/2015 (Attachment #23). Individual #2 recently had her annual assessment updated by the Program Supervisor and sent out to all team members prior to the ISP meeting (Attachment #24). |
| Implemented |
2380.183(4) | Individual #1 received 1:1 staffing at the day program. Their Individual Support Plan (ISP) included an outcome titled ¿staying active.¿ the outcome listed their 1:1 support being needed for completion of the outcome. Progress was determined when their 1:1 could "fade". There wasn't a protocol and schedule outling the specific period of time for Individual #1 to be without direct supervision or the method of evaluation used to determine progress towards the expected outcome to achieve the higher level of independence. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual¿s current assessment states the individual may be without direct supervision and if the individual¿s ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | 2380.183(4) The regulation was reviewed with the Program Supervisor by the Assistant Director on 10/28/2015 (Attachment #7). A fade plan was developed by the Program Supervisor outlining the requirements for reduction in 1:1 support (Attachment #8). A copy of the fade plan was emailed to the Supports Coordinator to update individual #1¿s ISP (Attachment #9). |
| Implemented |
2380.183(5) | The Individual Support Plan (ISP) for Individual #1 did not have a protocol to address their social, emotional and environmental needs. Individual #1 was prescribed Lithium, Guanfacine Ziprasidone, and Gabapentin for Impulse Control Disorder, Aggitation, and Mood Disorder. The day program used Individual #1's behavior support plan from the residential program as their protocol to addresss the individual's social, emotional, and environmental needs. However the ISP for Individual #1 stated that the behavior support plan listed in the ISP was only used by their residential provider. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | 2380.183(5) The regulation was reviewed with the Program Supervisor by the Assistant Director on 12/09/2015 (Attachment #10). A plan for addressing social, emotional and environmental needs was developed and implemented for individual #1 (Attachment #11). The SEEN plan was emailed to the Supports Coordinator to be added to the ISP (Attachment #12). |
| Implemented |
2380.183(7)(i) | The Individual Support Plan (ISP) for dominic did not include his potential to advance in vocational programming. The ISP stated that Individual #1 used to work on vocational skills while he was in high school. However he graduated high school in the spring of 2014. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming. | 2380.183(7)(i) The regulation was reviewed with the Program Supervisor by the Assistant Director on 12/09/2015 (Attachment #13) An email was sent to the Supports Coordinator for individual #1 on 12/11/2015 to add information to the ISP regarding potential to advance in vocational programming (Attachment #14). |
| Implemented |
2380.183(7)(iii) | The Individual Support Plan (ISP) for dominic did not include his potential to advance in competitive community-integrated employment. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Competitive community-integrated employment. | 2380.183(7)(iii) The regulation was reviewed with the Program Supervisor by the Assistant Director on 12/09/2015 (Attachment #15). An email was sent to the Supports Coordinator for individual #1 on 12/11/2015 to add information to the ISP regarding potential to advance in competitive community integrated employment (Attachment #16). |
| Implemented |
2380.184(b) | Individual #1 did not sign the Individual Support Plan (ISP) signature sheet and the day program provider could not find record of his attendance to his ISP meeting. | At least three plan team members, in addition to the individual, if the individual chooses to attend, shall be present for an ISP, annual update and ISP revision meeting. | 2380.184(b) The regulation was reviewed with the Program Supervisor by the Assistant Director on 10/28/2015 (Attachment #5). Program Supervisor did not have a copy of the signature form from the ISP meeting at the time of the licensing inspection. A copy was obtained to show that individual #1 did attend his annual ISP meeting on 1/23/15 (Attachment #6). |
| Implemented |
2380.186(c)(2) | The Individual Support Plan (ISP) reviews for Individual #1 did not review his 1:1 supervision support that was needed at the day program. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | 2380.186(c)(2) The regulation was reviewed with the Program Supervisor by the Assistant Director on 10/28/2015 (Attachment #1) An ISP review was completed for individual #1 on 10/26/2015 that included a review of the 1:1 support needed at day program (Attachment #2). |
| Implemented |
2380.186(d) | The Individual Support Plan (ISP) reviews for Individual #1 were not sent to his behavior support provider or their family member Joy Baskerville. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | 2380.186(d) The regulation was reviewed with the Program Supervisor by the Assistant Director on 10/28/2015 (Attachment #3). An ISP review was held for individual #1 on 10/26/2015 and copies of the ISP review were then sent out to all team members (Attachment #4). |
| Implemented |